malignant obstructive jaundice By James Monteiro de Barros, - - PowerPoint PPT Presentation

• 1. Biliary Drainage vs. No Biliary Drainage
• 2. Patency of Biliary Stents in Patients with

malignant obstructive jaundice

By James Monteiro de Barros, Niroshini Rajaretnam & S Aroori

Biliary Drainage

• Obstructive jaundice is common
• Malignant and benign causes
• Before 1980s- surgery is the treatment of choice
• Jaundice can lead to

– Hepatic dysfunction – Cholangitis – Cirrhosis – Severe pruritus – Weight loss

Benefits of Biliary Drainage

• Less yellow
• Itching goes away
• Patients feels better
• Taste/eating improves

Types of Biliary Stents

• Plastic
• Metal

– Covered – Uncovered

• Length
• Diameter

Metal stents

• Resectable tumours – we would prefer short

covered metal stent

• Life expectancy < 4 months – Plastic stent
• Life expectancy > 4 months – Metal stent

Types of Biliary Drainage

• Endoscopic drainage (EBD)

– External – Internal

• Percutaneous drainage (PTBD)

– External (Nasal) – External (Skin)

EBD

• Bleeding
• Pancreatitis
• Blocked stent
• Cholangitis
• Size of the stent- standard duodenoscope 4.2mm

diameter

• No loss of electrolyte abnormalities

PTBD Disadvantages

• Dislodgement
• Collapse of the stent
• Discomfort
• Blockage
• Cholangitis
• Electrolyte abnormalities
• No sphincterotomy

Key Questions

• 1) How does routine pre-op drainage vs non pre-op drainage

compare in terms of mortality and morbidity?

• 2) How does pre-op biliary drainage through endoscopic and

percutaneous approach compare in terms of efficacy, complications, survival, quality of life and cost?

• 3)Hoes does plastic and metal stents compare for pre-op

drainage in terms of re-intervention, survivability, mortality and cost?

Evidence

• ESG October 2017

Against routine pre-op biliary drainage Not recommended for malignant biliary

• bstruction who need surgery.

Exceptions Cholangitis, delayed surgery, neo-adjuvant and intense pruritus. Bilirubin > 250. 10 Meta-analyses found no difference in mortality, but increased morbidity if they have had drains.

Evidence

• If drainage is indicated

– Self expanding metal stents were associated with lower rates of re-

• intervention. 3.4% vs 14.8% (plastic).

– No difference in mortality and morbidity between the stents. – Fully covered metal stents show longer patency compared to uncovered metal and plastic stents in patients undergoing neo- adjuvant chemotherapy – Presence of stents does not affect resectability but prolongs the duration of surgery. – External drainage vs internal drainage has decreased survival

Scope

• Study looking at patients referred to Plymouth

HPB MDT with presumed

– Head of Pancreas Cancer – Ampullary Cancer – Duodenal Cancer – Distal cholangiocarcinomas – Hilar cholangiocarcinomas

• Retrospective study

– 2011 to 2014 inclusive Requiring a biliary stent

Hypotheses, Aims and Objectives

• Hypothesis A

– Are patients with curative intent having delayed

• perations due to complications arising from their

stents

• Hypothesis B

– Patients with curative intent require stents as surgery cannot be achieved in the required time

Jan 2011-Aug 2012

• 215 referrals to the HPB MDT

Hospital Number of Patients HoP & Duodenal Ca Amp Ca Cholangio Barnstaple 17 12 2 3 Exeter 29 17 6 6 Plymouth 100 66 8 26 Torbay 33 17 5 11 Truro 36 29 1 6

Plymouth

• 50 female and 50 male
• Age at referral
• Presentation

35 64 71 78 91

Initial Outcomes

100 patients

• 2 – no stent/palliated
• 3 – theatres without stent
• 40- stented theatre after stent
• 55 – palliative stent

Theatre Cohort

• 40 with curative intent (stented group)

– 25 had a Whipple’s procedure – 4 Extra hepatic bile duct reconstructions – 2 liver resections and bile duct reconstructions – 8 bypass operations for locally advanced cancer or metastases – 1 open and close case

Theatre Cohort

Wait after stent

39 patients <2 weeks 4-8 weeks 2-4 weeks >8 weeks Neoadjuvant chemo 1 patients 10 patients 21 patients 6 patients 2 patients

3 Whipple’s 1 bypass 1 liver 1 Roux 2 Whipple’s 13 Whipple’s 5 bypass 1 liver 1 Roux 1 open & close 7 Whipple’s 1 bypass 1 liver 1 Roux 1 Whipple’s

Were stent complications a cause for delayed

• perations?
• 9 /40 (22.5%) re-admissions
• 7/40 (17.5%) re-admissions due to Blocked

stents/stent complication

• 2-4 weeks post stent placement

– 1 stent complication requiring admission. Bypass as mets found

• 4-8 weeks

– 6 stent complications requiring admission. All of them plastic stents (with complications 4-21 days after initial ERCP/PTC). All of them went onto a Whipple’s

• >8 weeks

– 2 stent complications during prolonged initial admission due to pancreatitis/AKI. Both went onto a Whipple’s

Palliative Stents

• 3/55 (5%) died within 7 days of insertion
• 29/55 (53%) patients did not have any

admissions due to stent blockages/stent complications

– 4 plastic (18-88 days) – 25 metal (13-612 days) median 273 days

• 5/55 (9%) patients required an exchange of

stent

Blocked Palliative Stents

• 17/55 (31%) had at least one blockage/stent

complication

• 10 Plastic (8-459 days) median 56 days

– 9 having a metal replacement stent & 1 palliated

• 9 Metal (66-1454 days) median 274 days

– 7 having a metal replacement stent & 2 palliated

Survival

• 1 patient with a P2N0R0 ampullary cancer is still

alive > 6 years with no recurrence

• 4 patients who underwent a Whipple’s or bile

duct reconstruction are still alive - histology gallstones or chronic pancreatitis.

• Curative intent

– 33-2136 days, median 682

• Palliative cohort

– 5-1995 days, median 149 – Outlier at 1995 days with presumed low CBD

• cholangiocarcinoma. No treatment as too co-morbid

Conclusion

• Study is still ongoing
• Tentative conclusion

– Whilst stents do cause admissions at 17.5% – More data is required to demonstrate if it causes major delays in patients having surgery.